Glossary
Certain terms used on this website and in the handbook have very specific meanings. They are defined here for your information.
- Accident - Coinsurance
- Comprehensive Major Medical - Disposable Supplies
- Doctor/Physician - First Eligible
- Formulary - Hospital
- Illness - Morbid Obesity
- Network Provider - Partial Hospitalization
- Pharmacy Benefit Manager - Prudent Layperson
- Qualified Medical Child Support Order (QMCSO) - Sound, Natural Teeth
- Specialty Care Physician/Specialist - Terminated Vested Subscriber
Accident - An unforeseen and unavoidable event resulting in an injury.
Administrative Appeal - An appeal procedure involving MCHCP administrative issues such as eligibility and effective date of coverage. Go to Administrative Appeal section
Adverse Determination - Go to Health Plan Utilization Review section
Allowable Expense - Charges for services rendered or supplies furnished by a health plan that would qualify as covered expenses for which the program pays in whole or in part, subject to any deductible and coinsurance amounts.
Appeal - A written complaint submitted by or on behalf of a member regarding one of the following:
- Availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review; or
- Claim payment, handling or reimbursement for health care services. Go to Complaint & Appeal Procedures section
Assignment - When a doctor agrees to accept Medicare’s fee as full payment.
Benefit Period - The 365 days immediately following the first date of like services.
Benefit Year - Go to Calendar Year in this section.
Birthday Rule - If both parents have medical coverage, the primary plan for dependent children is the plan of the parent whose birthday occurs first in the calendar year. If birthdays occur on the same day, the parent’s coverage that has been in effect longest is primary.
Calendar Year - The period of time from January 1 through December 31. This is the period during which the total amount of annual benefits is calculated. All annual deductibles and benefit maximums accumulate during the calendar year.
Chiropractic Services - The examination, diagnosis, adjustment, manipulation and treatment of malpositioned articulations and structures of the body. The adjustment, manipulation and treatment shall be directed toward restoring and maintaining the normal neuromuscular and musculoskeletal function and health.
Claims Administrator - An organization or group responsible for the processing of claims and associated services.
Coinsurance - The shared portion of payment between the plan and the subscriber where each pays a percentage of covered charges.